Mutrakrichha (Uti): a Review Based on Ayurveda and Modern Perspectivee

wjpmr, 2017,3(8), 128-132 SJIF Impact Factor: 4.103 WORLD JOURNAL OF PHARMACEUTICAL Review Article Bakhtyar et al. World Journal of Pharmaceutical and Medical ResearchISSN 2455 -3301 AND MEDICAL RESEARCH www.wjpmr.com WJPMR

MUTRAKRICHHA (UTI): A REVIEW BASED ON AYURVEDA AND MODERN PERSPECTIVEE

Dr. Bakhtyar Asharafi*1, Dr. Ajay Goswami2, Dr. Bhima Devi3 and Dr. Rakesh Sharma4

1,2P.G. Scholar, Deptt of Kaumarbhritya, Rajeev Gandhi govt. P.G. Ayurvedic Medical College Paprola, Dist. Kangra, Himachal Pradesh, India, Pin-176115. 3Assistant Professor, Deptt of Kaumarbhritya, Guru Nanak Ayurvedic Medical College Muktsar, Punjab, India, Pin- 152026. 4Reader and H.O.D., Deptt of Kaumarbhritya, Rajeev Gandhi govt. P.G. Ayurvedic Medical College Paprola, Dist.Kangra, Himachal Pradesh, India, Pin-176115.

*Corresponding Author: Dr. Bakhtyar Asharafi P.G. Scholar, Deptt of Kaumarbhritya, Rajeev Gandhi govt. P.G. Ayurvedic Medical College Paprola, Dist. Kangra, Himachal Pradesh, India, Pin-176115.

Article Received on 09/07/2017 Article Revised on 30/07/2017 Article Accepted on 20/08/2017

ABSTRACT

The term Mutrakrichha comes under the disorders of Mutravaha Srotas, and mainly deals with shool (pain) and kricchrata (dysuria). Description of this disease in almost all-important classical texts reflects its prevalence in ancient period. Acharya Charaka has described eight types of Mutrakrichha. Charaka has also mentioned eight type of Mutragatha. Mutraghata and Mutrakrichha separately described by Acharya Sushruta in Uttar-tantra. In Mutrakrichha, the vitiated Pitta Dosha along with Vata (mainly Apana Vayu) on reaching Vasti (bladder) afflicts the Mutravaha Srotas due to which the patient feels difficulty in micturition along with symptoms like Peeta mutrata, Sarakta mutrata, Sadaha mutrata, Saruja mutrata and Muhur-muhur mutrata. The above mentioned symptomatology has close resemblance with urinary tract infections, as described in modern texts specifically lower urinary tract infections (urethritis and cystitis). Therefore in present article attempt has been made to define Mutrakrichha on scientific grounds vis-a-vis urinary tract infection.

KEYWORDS: Mutrakrichha, Shool, Mutraghata, Peeta Mutrata, Urniary Tract Infection.

1.0 INTRODUCTION respiratory tract infections.[4] Incidence and degree of morbidity and mortality from infections are greater with In our classical text the urinary disorders are described in those in the urinary tract than with those of the upper the form of 8 types of Mutrakrichha, 13 types of respiratory tract. Bacteria are by far the most common Mutraghatas,[1] 4 types of Ashmaris and 20 types of invading organisms but fungi, yeasts and viruses also Prameha. Acharya kashyapa had also described the sign produce urinary tract infections. Thus, urinary tract and symptoms of Mutrakriccha in Vedna adhyaya.[2] A infection is potentially a serious condition and failure to healthy urinary tract is generally resistant to infections. realize that this may lead to development of serious However, for anatomical reasons female lower urinary chronic pyelonephritis and chronic renal failure. With the tract is more susceptible. Predisposing factors for introduction of effective antibiotics problem has been recurrent Urinary tract infection include female sex, age solved to some extent but the use of, antibiotics have below 6 months, obstructive uropathy, severe limitations like side effects, chances of reinfection and vesicoureteric reflux, constipation and repeated relapse even after long-term therapy. Simultaneously catheterization poor hygienic conditions and increasing incidence of resistance and high cost of environment, poverty and illiteracy also contribute to the therapy are common problems. increasing percentage of urinary tract infections. Urinary tract infections occur in 1% of boys and 1-3% of girls.[3] 2.0 Ayurvedic Perspective These infections are the common complications during Mutra is an outcome product digestion of food and pregnancy, diabetes, polycystic renal disease and in other metabolism in the body it is passes through urethra.[5] In immune compromised patients. Urinary tract infections both Mutraghata and Mutrakrichha, Krichhrata are the leading cause of gram-negative sepsis in (dysuria) and Mutra-vibandhta are simultaneously hospitalized patients. They are important cause of present but in Mutrakrichha there is predominance of morbidity and might result in renal damage, often in Krichhrata (dysuria). association with vesicoureteric reflux (VUR). Urinary tract infections are second in frequency after upper www.wjpmr.com 128 Bakhtyar et al. World Journal of Pharmaceutical and Medical Research

2.1 Definition of Mutra Krichha Antahparimarjana chikitsa The painful voiding of urine is known as Mutrakrichha.  Shodhana- Niruha vasti, Uttara vasti with vata In this disease patient has urge to micturate, but he shamak kwath like dashmoola kwath. passes urine with pain.  Shamana- Amritadi kwatha, Sthiradi aushadha, Shwadanshtra taila, traivritta taila(Su.), Mishraka 2.2 Nidana (Etiology) sneha. It can be concluded that Vyayama, adhyashan, ruksha sevana, yana gamana are causative factors for vata Pittaja Mutrakrichra chikitsa prakopa.[6] Tikshna aushadha, amla sevana causes pitta Bahirparimarjana chikitsa– Sheeta Parisheka, prakopa[7] and Anupa mamsa sevana, vyayama, Avagahana in cold water,pralepana with chandan and adhyashan causes kapha prakopa[8] So these Nidanas karpur.[17] cause vitiation of Doshas along with Stroto-dushti of Mutrvaha strotas. Stroto-dusti will cause kha-vaigunya Antahparimarjana chikitsa in Mutravaha srotas. These factor leads to Mutrakriccha.  Shodhana- Virechana with tikta evam madhur These etiological factors can be summarized as: kashaya, Uttara vasti.  Shamana- Shatavaryadi kwatha (Ch.), Haritakyadi Aharaja Nidana kwatha, Trinapanchmula kwatha(Y.R.),  Adhyashana, Trinapanchamula churna(Su.),ervaru  Ajirna beeja,yashtimadhu,devdaru with tandul dhavan.  Ruksha anna sevana  Tikshna aushadha sevana Kaphaja Mutrakrichha chikitsa  Ruksha madya sevana Bahirparimarjana chikitsa Svedana, Abhyanga with taila containing tikta ushna Viharaja Nidana dravya.  Yana gamana  Ativyayama Antahparimarjana chikitsa  Aghata  Shodhana- Vamana, Niruha vasti with kshara,tikshna,and katu dravya. Partantra Nidana  Shamana- Vyoshadi churna praval bhasma(Ch.),  Kaphaja arsha[9] shwadanshtradi kwatha, trikankantakadi ghrita,yava  Ajirna[10] bhaksh,takra  Vasti vidradhi[11]  Gulma[12] Sannipattaja Mutrakrichha chikitsa  Udavarta[13] In Sannipataja Mutrakrichra the treatment should be done according to vata sthana. 2.3 Rupa (Symptomatology) Pratyatma lakshana “The dosha which is more dominant is treated first” Ekw=L; d`PNªs.k egrk nq%[ksu izo`fÙk%A[14] Antahparimarjana chikitsa **jkseg’kksZvaxg’kZ”pew=dkys p osnukA  Shodhana- If kapha is predominant then vamana, if ew=d`PNsn”kR;ks’BkScfLrLi`f”Rkikf.kukAA**[15] pitta is predominant then virechana and if vata is predominant then vasti karma should be perormed. 2.4 Chikitsa (Management)  Shamana- Pashanbhedadi yoga, Brihatyadi kwatha,  Shamana chikitsa: It includes Mutra-vishodhaniya, Gudadugdha yoga, dhatryadi yoga. mutra-virechaniya, mutra-virajaniya and ashmarihara dravyas. Raktaj Mutrakrichha chikitsa  Shodhana chikitsa: It includes diuretic drugs & It should be managed as sadyovrana. uttara vasti which dilutes and flushes various infective agents along with urine. Shakritajanya Mutrakrichha chikitsa  Bahirparimarjana chikitsa: It includes medicines Vatahara kriya is done in shakritjanya Mutrakrichra. that can be used externally in the form of douches, fomentation, showers, poultices and ointment etc. Bahirparimarjana chikitsa Abhyanga, Svedana, Avagahana. Specific Management Vataja Mutrakrichra chikitsa Antahparimarjana chikitsa Bahirparimarjana chikitsa  Shodhana: vasti Abhyanga, Svedana, upanaha,,Vatashamaka dravayas  Shamana : Churna kriya like dashmool,Eranda, Nirgundi,Parisheka on Kati Pradesh with Vatashamak Taila and Kwatha.[16] Some other important formulations include  Varunadi kwatha  Varunshigruadi kwatha

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 Gokshuradi guggulu considered superficial or (mucosal) infections,  Gokshuradi kwatha pyelonephritis and renal suppuration signify tissue  Chandanasava invasion. The 3 basic form of UTI are pyelonephritis,  Chandraprabha vati cystitis and asymptomatic bacteriuria. Focal  Trivikrama rasa pyelonephritis and renal abscess are less common.[22]  Chandrakala rasa From a microbiological perspective, urinary tract  Pathya: Purana shali, yava, kshara,takra, dugdha, infection exists when pathogenic microorganisms are dadhi, jangal mamsa, mudga yusha,, trapusha, detected in the urine, urethra, and kidney. Symptoms of nadeya jala, sharkara, kushmanda, patola patra, dysuria, urgency, and frequency unaccompanied by ardraka, gokshura, puga, narikela, laghu ela, significant bacteriuria have been termed as acute urethral karpura. syndrome. Although widely used, this term lacks  Apathya: Tambula, matsaya, lavana, pinyaka, anatomic precision because many cases so designated are hingu, tila, sarshapa, masha, karira, tikshna, vidahi, actually bladder infections. Moreover, since the ruksha, amla dravya, virudhashana, vishamashana, causative agent can usually be identified in these Yana gamana, vega dharana. patients, the term syndrome- implying unknown causation is inappropriate. 3.0 Modern Perspective Urinary tract infections have plagued mankind long 3.2 Etiology before bacteria were recognized as the causative agents Bacterial infection are the most common cause of UTI, of disease and before urology became an established with E.coli being the most frequent pathogen, causing medical specialty. The Ebers papyrus from ancient Egypt 75-90% of UTIs.[23] Other bacterial sources of UTI recommended herbal treatment to ameliorate urinary include Klebsiella, Proteus, Enterococcus species, symptoms without providing insight into pathological Staphylococcus, saprophyticus especially among female mechanism. Hippocrates believed that disease was adolescent and sexually active females and caused by disharmony of the four humors and Streptococcus group B especially among neonates. Fungi accordingly diagnosed urinary disorders.[18] Urinary tract (Candida species) may also cause UTIs, especially after infection refers to both microbial colonization of the instrumentation of Urinary tract. Adenovirus is a rare urine and tissue invasion of any structure of the urinary cause of UTI and may cause hemorrhagic cystitis. tract. Bacteria are most commonly responsible, although yeast, fungi and viruses may produce urinary infection. 3.3 Treatment[24] Infants and young children with UTI may present with Acute cystitis should be treated promptly to prevent few specific symptoms Older pediatric patients are more possible progression to pyelonephritis. If the symptoms likely to have symptoms and findings attributable to an are severe, a specimen of bladder urine is obtained for infection of urinary tract.[19] Differentiating cystitis from culture, and treatment is started immediately. If the pyelonephritis in the pediatric patient is not always symptoms are mild or the diagnosis is doubtful, possible, although children who appear ill or who present treatment can be delayed until the results of culture are with fever should be presumed to have pyeleronephritis known, and the culture can be repeated if the results are if they have evidence of UTI. uncertain. For example, if a midstream culture grows between 104and 105colonies of a gram-negative Escherichia coli are the most common causative organism, a second culture may be obtained by organism of this disease causes approximately 80% of catheterization before treatment is initiated. If treatment acute infections in patients without catheters. Other is initiated before the results of a culture and sensitivities gram-negative bacilli, especially Proteus and Klebsiella are available, a 3- to 5-day course of therapy with and occasionally Enterobacter, account for a smaller trimethoprim-sulfamethoxazole is effective against most proportion of uncomplicated infections. Gram-positive strains of E. coli. Nitrofurantoin (5–7 mg/kg/24 hr in 3 to cocci play a lesser role in urinary tract infections, 4 divided doses) also is effective and has the advantage nonetheless Staphylococcus saprophyticus, Enterococci, of being active against Klebsiella-Enterobacter Staphylococcus aureus are associated with acute urinary organisms. Amoxicillin (50 mg/kg/24 hr) also is tract infection in young females and in-patient with renal effective as initial treatment but has no clear advantages stone or previous instrumentation.[20] over sulfonamides or nitrofurantoin.

3.1 Definition In acute febrile infections suggestive of pyelonephritis, a Urinary tract infection is an infection that affects part of 10- to 14-day course of broad-spectrum antibiotics the urinary tract.When it affects the lower urinary tract it capable of reaching significant tissue levels is preferable. is known as bladder infection (cystitis) and when it Children who are dehydrated, are vomiting, or are unable affects the urinary tract it is known as kidney infection to drink fluids, are ≤1 mo of age, or in whom urosepsis is (pyelonephritis). Symptoms from a lower urinary tract a possibility should be admitted to the hospital for include pain with urination, frequent urination, and intravenous rehydration and intravenous antibiotic feeling the need to urinate despite having an empty therapy. Parenteral treatment with ceftriaxone (50–75 bladder.[21] Infections of the urethra and bladder are often mg/kg/24 hr, not to exceed 2 g) or ampicillin (100

www.wjpmr.com 130 Bakhtyar et al. World Journal of Pharmaceutical and Medical Research mg/kg/24 hr) with an aminoglycoside such as gentamicin vaginal flora, and cranberry juice, which prevents (3–5 mg/kg/24 hr in 1 to 3 divided doses) is preferable. bacterial adhesion and biofilm formation, but these The potential ototoxicity and nephrotoxicity of agents have not proved beneficial in preventing UTI. aminoglycosides should be considered, and serum creatinine and trough gentamicin levels must be obtained The main consequences of chronic renal damage caused before initiating treatment, as well as daily thereafter as by pyelonephritis are arterial hypertension and renal long as treatment continues. Treatment with insufficiency; when they are found they should be treated aminoglycosides is particularly effective against appropriately. Pseudomonas spp., and alkalinization of urine with sodium bicarbonate increases their effectiveness in the 4.0 CONCLUSION urinary tract. Oral 3rd-generation cephalosporins such as  Increasing prevalence of UTI is a global issue of cefixime are as effective as parenteral ceftriaxone against concern due to associated long term compromise in a variety of gram-negative organisms other than the quality of life. Pseudomonas, and these medications are considered by  Urinary Tract Infections mentioned in Modern some authorities to be the treatment of choice for oral Medicine resembles with Mutakrichha. therapy. Nitrofurantoin should not be used routinely in  This disease is an important cause of renal damage, children with a febrile UTI because it does not achieve school absentees and frequent visit of the significant renal tissue levels. The oral fluoroquinolone paediatricians, clinics or hospital. ciprofloxacin is an alternative agent for resistant  It is a Vata Predominant Tridoshaj disease involving microorganisms, particularly Pseudomonas, in patients Mutravaha Srotas with dushti of Mutra and Ambu. older than 17 yr. It also has been used in younger  In both Ayurveda and modern management, primary children with cystic fibrosis and pulmonary infection prevention (Nidanprivarjanam) strategy has been secondary to Pseudomonas and is used on occasion for given priority. short-course therapy in children with Pseudomonas UTI.  Uncircumcised male infants appear to be at However, the clinical use of fluoroquinolones in children increased risk of UTI in the first three months of should be restricted because of potential cartilage life. damage that has been seen in research with immature  A girl with voiding dysfunction is at increased risk animals. The safety and efficacy of oral ciprofloxacin in for recurrent UTI, because the reflux of urine laden children is under study. In some children with a febrile with bacteria from the distal urethra in to the UTI, intramuscular injection of a loading dose of bladder. ceftriaxone followed by oral therapy with a 3rd-  Boys with true phimosis without abnormal voiding generation cephalosporin is effective. A urine culture 1 showed high incidence of Urinary Tract Infection, wk after the termination of treatment of a UTI ensures particularly in the form of pyelonephritis, was noted that the urine is sterile; in most children, this is to be high. unnecessary, because the cultures often are negative.  UTI causes by micro-organism, so patient should

maintain their proper hygiene. Caregivers can help Children with a renal or perirenal abscess or with in preventing the disease in children by teaching infection in obstructed urinary tracts often require good hygiene, maintaining healthy hydration and by surgical or percutaneous drainage in addition to being aware your child‟s daily bathroom habits. antibiotic therapy and other supportive measures.

REFERENCES In a child with recurrent UTIs, identification of predisposing factors is beneficial. Many school-aged 1. Ch.Su.19/1 Caraka Samhita, with Ayurveda Dipika girls have voiding dysfunction; treatment of this commentary by Cakrapanidatta, Chowkhamba condition often reduces the likelihood of recurrent UTI. Krishnadas Academy, 2nd edition, Varanasi. Some children with urinary tract infections void 2. Ka.Su.25/21 Bhishgacharya, Shri Satyapala. infrequently, and many also have severe constipation. Kashyapa Samhita “Vidyotini” Hindi commentary, Counseling of parents and patients to try to establish Chaukhambha Sanskrit Sansthan Varanasi, 2004. more normal patterns of voiding and defecation may be 3. IAP Textbook of Pediatrics - IVth edition. helpful in controlling recurrences. Prophylaxis against 4. www.ncbi.nlm.nih.gov. reinfection, using sulfamethoxazole-trimethoprim, 5. Su.Sa.9/7 Shastri, Kaviraj Ambikadutta Sushruta trimethoprim, or nitrofurantoin at ⅓of the normal Samhita commentary “Ayurveda Tattva Sandipika” therapeutic dose once a day, often is effective. part 1, Chaukhambha Sanskrit Sansthan, Varanasi, Prophylaxis with amoxicillin or cephalexin also may be 1995. effective, but the risk of breakthrough UTI may be 6. Su.Su.21/19 shastri, Kaviraj Ambikadutta Sushruta higher because bacterial resistance may be induced. Samhita commentary “Ayurveda Tattva Sandipika” Other indications for long-term prophylaxis (e.g., part 1, Chaukhambha Sanskrit Sansthan, Varanasi, neurogenic bladder, urinary tract stasis and obstruction, 1995. reflux, calculi) are discussed in other chapters. There is 7. Su.su.21/20 Shastri, Kaviraj Ambikadutta Sushruta interest in probiotic therapy, which replaces normal Samhita commentary “Ayurveda Tattva Sandipika”

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part 1, Chaukhambha Sanskrit Sansthan, Varanasi, Elsevier, a Division of Reed Elsevier India Private 1995. Limited, New Delhi, 18th Ed.2008 chapter 538. 8. Su.su.21/21 Shastri, Kaviraj Ambikadutta Sushruta Samhita commentary “Ayurveda Tattva Sandipika” part 1, Chaukhambha Sanskrit Sansthan, Varanasi, 1995. 9. Ch.Ch.14 Caraka Samhita, with Ayurveda Dipika commentary by Cakrapanidatta, Chowkhamba Krishnadas Academy, 2nd edition, Varanasi. 10. Ch.Ch.15/49 Caraka Samhita, with Ayurveda Dipika commentary by Cakrapanidatta, Chowkhamba Krishnadas Academy, 2nd edition, Varanasi. 11. Ch. Su. 17/101 Caraka Samhita, with Ayurveda Dipika commentary by Cakrapanidatta, Chowkhamba Krishnadas Academy, 2nd edition, Varanasi. 12. Ch.Ch.5 Caraka Samhita, with Ayurveda Dipika commentary by Cakrapanidatta, Chowkhamba Krishnadas Academy, 2nd edition, Varanasi. 13. Ch.Ch26/8 Caraka Samhita, with Ayurveda Dipika commentary by Cakrapanidatta, Chowkhamba Krishnadas Academy, 2nd edition, Varanasi. 14. Ma.Ni.30/2 (Madhukosha) Madhavakar, Madhava Nidana, revised by Vijayarakshita and Kanthadatta „Madhukosha‟ commentary and Vidyotini Hindi commentary by Ayuredacharya Shri Sudarshana Shashtri, Edited by Ayurvedacharya Shri Yadunandana Upadhyaya, Published by Chaukhambha Publications, New Delhi, Edition 32, Year of reprint 2002. 15. Ka.Su.25/21 Bhishgacharya, Shri Satyapala. Kashyapa Samhita “Vidyotini” Hindi commentary, Chaukhambha Sanskrit Sansthan Varanasi, 2004. 16. Ch.Chi.26/45 Caraka Samhita, with Ayurveda Dipika commentary by Cakrapanidatta, Chowkhamba Krishnadas Academy, 2nd edition, Varanasi. 17. Ch.Chi.26/59 Caraka Samhita, with Ayurveda Dipika commentary by Cakrapanidatta, Chowkhamba Krishnadas Academy, 2nd edition, Varanasi. 18. www.who.int/en/. 19. I.A.P. Textbook of Pediatrics - IVth edition, p. 751, 2009. 20. Harrison‟s principles of internal medicine by Fauci, Braunwald, Kapser, Hauser Longo, Jameson, Loscalzo, 17th edition p. 5665. 21. Harrison‟s principles of internal medicine by Fauci, Braunwald, Kapser, Hauser Longo, Jameson, Loscalzo, 17th edition p. 5665. 22. Richard E, Behsnanh Robert M. Kliegman Hal B Jenson; Nelson Textbook of Pediatrics. Saunders Elsevier, a Division of Reed Elsevier India Private Limited, New Delhi, 18th Ed.2008 chapter 538. 23. Harrison‟s principles of internal medicine by Fauci, Braunwald, Kapser, Hauser Longo, Jameson, Loscalzo, 17th edition p. 5665. 24. Richard E, Behsnanh Robert M. Kliegman Hal B Jenson; Nelson Textbook of Pediatrics. Saunders